sharing design and implementation experiences - mercer
TRANSCRIPT
AUGUST 29, 2017
Deidra B. Abbott, MPHKim Donica, PrincipalBob Karsten, ASA, MAAAMercer
Angela Medrano New Mexico Human Services Department
R. Neil Vance, PhD, FSANew Jersey Department of Human Services
Kevin HancockPennsylvania Department of Human Services
M L T S S P R O G R A M S :S H A R I N G D E S I G N A N D I M P L E M E N T A T I O N E X P E R I E N C E S
2MERCER
Currently, there are 22 States with MLTSS Programs
M LT S S P R O G R A M SN AT I O N A L P E R S P E C T I V E
Source: NASUAD and CHCS Report - Demonstrating the Value of Medicaid MLTSS Programs (May 2017)
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M LT S S P R O G R A M SN AT I O N A L P E R S P E C T I V E
EXPANDHCBS
REDUCEFRAGMENTED
ACUTE ANDPRIMARY
CARE, BH AND LTSS
REDUCEADMINISTRATIVE
BURDENS
INCREASEEFFICIENCY
PROMOTECOMMUNITYINCLUSION
IMPROVEQUALITY OF CARE
AND HEALTHOUTCOMES FOR
PEOPLERECEIVING LTSS
INCREASEBUDGET
PREDICTABILITY
POTENTIAL TOBEND THE
COST CURVE
AS STATES EVALUATE/IMPLEMENT MLTSS, COMMON THEMES/GOALS IN THE DESIGNPROCESS EMERGE:
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M LT S S P R O G R A M ST O D AY ’ S S E S S I O N
OVERVIEW 3 STATEMLTSS
EXPERIENCES
DISCUSSCHALLENGES FACED& LESSONS LEARNED
ENCOURAGE INTERACTIVE DIALOG WITHSESSION PARTICIPANTS:
WHAT ARE YOUR STATE’S CONCERNS?
WHAT LESSONS DID YOUR STATE LEARN?
WHAT ARE YOUR GREATEST CONCERNSMOVING IN THIS DIRECTION?
IDENTIFYSIGNIFICANT
WINS
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M LT S S P R O G R A M ST O D AY ’ S PA N E L
Sta
te P
artn
ers • Angela Medrano
Deputy Medicaid DirectorNew Mexico
• R. Neil Vance, PhD, FSAActuary, NJ MedicaidNew Jersey
• Kevin HancockChief of Staff, OLTLPennsylvania M
erce
r Tea
m • Deidra Abbott, MPH
• Kim Donica, Principal
• Bob Karsten, ASA, MAAA
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M LT S S P R O G R A M SO V E R V I E W
PROGRAM NAME
PROGRAM EFFECTIVEDATE
WAIVER AUTHORITY
POPULATION SERVED
SERVICES INCLUDED
POPULATION/SERVICEEXCLUSIONS
CENTENNIAL CARE
JANUARY 2014 (MLTSS SINCE 2008 VIA CoLTS)
1115
702,000: ABD, WD, DE, CHILDREN, EXPANSION
ADULTS
NF, HCBS (INCLUDINGSELF-DIRECTION), AL, BH AND ACUTE CARE
I/DD CARVED-OUT
NJ FAMILY CARE
JULY 2014
1115
1,772,026: A BD, EXPANSION ADULTS, ADULTS, CHILDREN
NF, HCBS, AL, ACUTECARE, BH SUPPORTS
I/DD CARVED-OUT
COMMUNITYHEALTHCHOICES
JANUARY 2018
1915(b)/1915(C)
420,618: 21+ DUALS ORMEET NF LOC CRITERIA
NF, HCBS, (INCLUDINGPARTICIPANT DIRECTION),
ACUTE CARE
I/DD POPULATION ANDBH SERVICES CARVED-
OUT
N E W J E R S E Y P E N N S Y LVA N I AN E W M E X I C OP R O G R A M S TAT S
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NEW MEXICOCENTENNIAL CARE
New Mexico Medicaid MLTSSAngela Medrano
Deputy Medicaid Director
August 29, 20178
New Mexico Medicaid Overview
• Expansion State• 915,000 enrolled in Medicaid • 702,000 members enrolled in Managed Care – Centennial
Care• 270,000 members enrolled as a result of expansion• 49,000 members receiving MLTSS• MLTSS since 2008
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MLTSS SuccessesIncreased number of Medicaid Members receiving Home & Community Based Services.
• Revised policy to allow all Medicaid members access home and community based services as long as they meet a Nursing Facility Level of Care (Assistance with 2 or more ADLs)
• Members no longer need a waiver slot if they meet this criteria
December 2013 CY2014 CY2015 CY2016
Agency Based &
Self Directed
HCBS21,300 24,013 27,836 29,799
Nursing Facility
(long term)3,529 3,711 3,591 3,661
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MLTSS Successes
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81.3% 81.1% 82.7% 85.3% 86.5% 86.4%
18.7% 18.9% 17.3% 14.7% 13.5% 13.6%
0%10%20%30%40%50%60%70%80%90%
100%
2011 2012 2103 2014 2015 2016
Proportion of Members In the Community vs Nursing Facility
Community Benefit Nursing Facility
Rebalanced Member Utilization of LTSS
MLTSS Successes
• New Mexico ranked in the 2nd best quartile in the 2014 national State Long Term Care Scorecard (published by AARP and the Commonwealth Fund)
• New Mexico’s system is especially strong in terms of:• Affordability and access (top quartile)
• Choice of setting and provider (top quartile)
• Effective Transitions across settings of care (second quartile)
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MLTSS Challenges
• Electronic Visit Verification implementation for Personal Care Services
• Budget Allotments for Members transitioning from Traditional Service Model (Agency Based) to Self-Directed Model
• Member Education on all Community Based Services• Development of Community Benefit Services Questionnaire
• Required LTSS membership on MCO Advisory Boards
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MLTSS Opportunities
• Medicaid Management Information System Replacement• Data Analytics for MLTSS Members
• Member claims data for service utilization
• Track Member Setting of Care
• Improve the functionality of our LTSS wait list
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NEW JERSEYFAMILYCARE
16Advisory, Consultative, Deliberative
Implementation of MLTSS in New Jersey: Successes and Struggles
R. Neil Vance, PHD, FSA, ActuaryNJ Division of Medical Assistance and Health Services (“Medicaid”)
NJ Dept. of Human Services
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PENNSYLVANIACOMMUNITY HEALTHCHOICES
O V E R V I E W
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WHAT IS COMMUNITY HEALTHCHOICES (CHC)?A Medicaid managed care program that will include physical health benefits and long‐term services and supports (LTSS). The program is referenced to nationally as a managed long‐term services and supports program (MLTSS).
WHO IS PART OF CHC?• Individuals who are 21 years of age or older and dually eligible for Medicare and Medicaid. Individuals with intellectual or developmental disabilities who are eligible for services through the Office of Developmental Program will not be enrolled in CHC.
• Individuals who are 21 years of age or older and eligible for Medicaid (LTSS) because they need the level of care provided by a nursing facility. This care may be provided in the home, community, or nursing facility. Individuals currently enrolled in the LIFE Program will not be enrolled in CHC unless they expressly select to transition from LIFE to a CHC managed care organization (MCO).
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420,618CHC POPULATION
94%DUAL-ELIGIBLE
64%270,114Healthy Duals
18%77,610
Duals in Nursing Facilities
12%49,759Duals in Waivers
4%15,821Non‐duals in
Waivers
2%7,314
Non‐duals in Nursing Facilities
16%IN WAIVERS
20%IN NURSING FACILITIES
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HOW DOES CHC WORK?
DHS• Pays a per‐member, per‐month rate (also called a capitated rate) to MCOs
• Holds the MCOs accountable for quality outcomes, efficiency, and effectiveness
MCO• Coordinates and manages physical health and LTSS for participants
• Works with Medicare and behavioral health MCOs to ensure coordinated care
• Develops a robust network of providers
Participants• Choose their MCO• Should consider the provider network and additional services offered by the MCOs
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WHAT ARE THE GOALS OF CHC?
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COMPARISON OF FFS VS. MANAGED CARE
FEE-FOR-SERVICE• Providers enroll as Medicaid providers
• Providers contract with the Commonwealth
• Providers bill PROMISe
MANAGED CARE• Providers enroll as Medicaid providers
• Providers contract with MCOs• Providers bill MCOs
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CURRENT BARRIERS TO LTSS• Participants show a tendency to under‐plan and under‐insure for long‐term care until there is a crisis.
• Confusing information about how to receive services.
• The system is difficult to navigate, particularly when transitioning between care delivery systems.
Lack of coordination between primary, acute, and LTSS organizations
Limited coordination between Medicare Special Needs Plans and LTSS organizations
• There is limited availability of long‐term care insurance products. Available products limit coverage and are costly.
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COVERED SERVICESFOR ALL PARTICIPANTS:Physical health services
All participants will receive the Adult Benefit Package, which is the same package they receive today.
This includes services such as:• Primary care physician• Specialist services• Please note: Medicare coverage will not change.
Behavioral health services
All participants will receive behavioral health services through the Behavioral Health HealthChoices MCOs.
This is new for Aging Waiver participants and nursing facility residents, who receive behavioral health services through the fee‐for‐service.
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COVERED SERVICESFOR PARTICIPANTS WHO QUALIFY FOR LTSS:• Home and community‐based long‐term services and supports including:
Personal assistance services Home adaptations Pest eradication
• Long‐term services and supports in a nursing facility
• Participant‐directed services will continue as they exist today
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CONTINUITY OF CARE• MCOs are required to contract with all willing and qualified existing Medicaid providers for 180 days after CHC implementation.
• Participants may keep their existing providers for the 180‐day continuity of care period after CHC implementation.
• For nursing facility residents, participants will be able to stay in their nursing facility as long as they need this level of care, unless they choose to move.
• The commonwealth will conduct ongoing monitoring to ensure the MCOs maintain provider networks that enable participants choice of provider for needed services.
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IDENTIFYING NEEDSSCREENING, COMPREHENSIVE NEEDS ASSESSMENT AND
REASSESSMENT
• CHC‐MCOs must:• Screen each new participant who are healthy duals within 90 days of the start date
• Conduct a comprehensive needs assessment of every participant who is determined NFCE
• Conduct a comprehensive assessment when the participant makes a request, self‐identifies as needing LTSS, or if either the CHC‐MCO or the Independent Enrollment Broker (IEB) identifies that the participant has unmet needs, service gaps or a need for service coordination
• Conduct a reassessment at least every 12 months unless a trigger event occurs
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PLANNINGCARE MANAGEMENT PLANS
A care management plan is used to identify and address how the participant’s physical, cognitive, and behavioral health care needs will be managed.
PERSON-CENTERED SERVICE PLANS (PCSP)
All LTSS participants will have a PCSP. The PSCP includes both the care management plan and the LTSS services plan.
PCSPs are developed through the person‐centered planning team process, which includes the participant, service coordinator, participant’s supports, and participant’s providers.
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SERVICE COORDINATION OBJECTIVES
• Every participant receiving LTSS will choose a service coordinator.
• The service coordinator will coordinate Medicare, LTSS, physical health services, and behavioral health services.
• They will also assist in accessing, locating and coordinating needed covered services and non‐covered services such as social, housing, educational and other services and supports.
• The service coordinator will also facilitate the person‐centered planning team.
• Each participant will have a person‐centered planning team that includes their doctors, service providers, and natural supports.
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WHERE IS IT NOW?
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PRIORITIES THROUGH IMPLEMENTATIONESSENTIAL PRIORITIES• No interruption in participant services• No interruption in provider payment
HOW WILL WE ENSURE NO INTERRUPTIONS?• The Department of Human Services (Department) is engaged with the MCOs in a rigorous readiness review process that looks at provider network adequacy and IT systems.
• The Department of Health must also review and approve the MCOs to ensure they have adequate networks.
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PRIORITIES THROUGH IMPLEMENTATION
READINESS REVIEW• Information systems
• Network adequacy
• Member materials and services
STAKEHOLDERCOMMUNICATION• Participants and caregivers
• Providers• Public
DHS PREPAREDNESS• General Information• Training• Coordination between offices
• Launch indicators
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NETWORK ADEQUACYPHYSICAL HEALTH • CHC‐MCOs will be required to meet the existing HealthChoices network adequacy
requirements.LTSS • National MLTSS network adequacy standards aren’t available.• The Department is working with consumers to help develop standards.• The Department is gathering information to establish a baseline of the number of
full‐time equivalents (FTEs) (i.e., personal assistance or nursing services) that are potentially needed to continue to provide services and meet the needs of the participants.
• The CHC‐MCOs are asking providers for this information during a provider’s initial enrollment with an MCO and on an ongoing basis.
• DHS will re‐evaluate network adequacy at the end of the 180‐day continuity of care period to ensure consumers have access to LTSS.
• The commonwealth will conduct ongoing monitoring to ensure the MCOs maintain provider networks that enable participants choice of provider for needed services.
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MANAGED CARE ORGANIZATIONS• The selected offerors were announced on August 30, 2016.
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COMMUNICATIONS
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CHC WEBSITE
www.HealthChoicesPA.com38
PARTICIPANTSAWARENESS FLYER• Mailed five months prior to implementation. Southwest: August 2017
AGING WELL EVENTS• Participants will receive invitations for events in their area. Southwest: August 2017
SERVICE COORDINATORS• Will reach out to their participants to inform them about CHC. Southwest: August 2017
NURSING FACILITIES• Discussions about CHC will occur with their residents. Southwest: August 2017
PRE-TRANSITION NOTICES AND ENROLLMENT PACKET• Mailed four months prior to implementation. Southwest: September 2017
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PROVIDERS• Bi‐weekly email blasts on specific topics
Examples: Billing, Service Coordination, Medicare, HealthChoices vs. CHC, Continuity of Care
• Established provider webpage
• Provider events in local areas to meet with MCOs and gain information about CHC
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RESOURCE INFORMATIONCOMMUNITY HEALTHCHOICES WEBSITEwww.healthchoicespa.com
MLTSS SUBMAAC WEBSITE www.dhs.pa.gov/communitypartners/informationforadvocatesandstakeholders/mltss/
CHC LISTSERV // STAY INFORMEDhttp://listserv.dpw.state.pa.us/Scripts/wa.exe?SUBED1=oltl-community healthchoices&A=1
EMAIL COMMENTS TO: [email protected]
PROVIDER LINE: 1-800-932-0939
PARTICIPANT LINE: 1-800-757-5042
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